Healthcare Provider Details

I. General information

NPI: 1922092485
Provider Name (Legal Business Name): JAMES KEITH RANDOLPH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 12/12/2021
Certification Date: 12/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3404 W SYLVANIA AVE
TOLEDO OH
43623-4467
US

IV. Provider business mailing address

2200 JEFFERSON AVE 4TH FLOOR
TOLEDO OH
43604-7101
US

V. Phone/Fax

Practice location:
  • Phone: 419-251-1206
  • Fax:
Mailing address:
  • Phone: 419-251-2673
  • Fax: 419-251-0916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704229515
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA08155
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: